ARTICLE IN PRESS

The Journal of Pain, Vol 00, No 00 (), 2018: pp 1−18

Available online at www.jpain.org and www.sciencedirect.com

Critical Review
AAPT Diagnostic Criteria for Fibromyalgia

D1X XLesley M. Arnold,D2X X* D3X XRobert M. Bennett,Dy4X X D5X XLeslie J. Crofford,Dz6X X D7X XLinda E. Dean,Dx8X X
D9X XDaniel J. Clauw,D10X{X D1X XDon L. Goldenberg,D12XjjX D13X XMary-Ann Fitzcharles,D14X X** D15X XEduardo S. Paiva,D16Xyy X
zz xx {{ x
D17X XRoland Staud,D18X X D19X XPiercarlo Sarzi-Puttini,D20X X D21X XDan Buskila,D2X X and D23X XGary J. MacfarlaneD24X X
*
Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, Ohio
y
Department of Medicine, Oregon Health and Science University, Portland, Oregon
z
Division of Rheumatology and Immunology, Department of Medicine, Vanderbilt University Medical Center, Nashville,
Tennessee
x
Epidemiology Group and Aberdeen Centre for Arthritis and Musculoskeletal Health, School of Medicine, Medical Sciences and
Nutrition, University of Aberdeen, Scotland, United Kingdom
{
Departments of Anesthesiology, Medicine (Rheumatology), and Psychiatry, University of Michigan Medical School, Ann Arbor,
Michigan
jj
Department of Medicine, Tufts University School of Medicine, Boston, Massachusetts, and Departments of Medicine and
Nursing, Oregon Health and Science University, Portland, Oregon
**
Division of Rheumatology, Department of Medicine, McGill University, Montreal, Quebec, Canada
yy
Division of Rheumatology, Department of Medicine, Universidade Federal do Parana, Curitiba, Brazil
zz
Division of Rheumatology, Department of Medicine, University of Florida, Gainesville, Florida
xx
Division of Rheumatology, Department of Medicine, Milan University, Milan, Italy
{{
Department of Medicine, H. Soroka Medical Center, Ben Gurion University of the Negev, Beer Sheva, Israel

Abstract: Fibromyalgia (FM) is a common chronic pain disorder that presents diagnostic challenges
for clinicians. Several classification, diagnostic and screening criteria have been developed over the
years, but there continues to be a need to develop criteria that reflect the current understanding of
FM and are practical for use by clinicians and researchers. The Analgesic, Anesthetic, and Addiction
Clinical Trial Translations Innovations Opportunities and Networks (ACTTION) public-private partner-
ship with the U.S. Food and Drug Administration (FDA) and the American Pain Society (APS) initiated
the ACTTION-APS Pain Taxonomy (AAPT) to develop a diagnostic system that would be clinically use-
ful and consistent across chronic pain disorders. The AAPT established an international FM working
group consisting of clinicians and researchers with expertise in FM to generate core diagnostic criteria
for FM and apply the multidimensional diagnostic framework adopted by AAPT to FM. The process
for developing the AAPT criteria and dimensions included literature reviews and synthesis, consensus
discussions, and analyses of data from large population-based studies conducted in the United King-
dom. The FM working group established a revised diagnosis of FM and identified risk factors, course,
prognosis, and pathophysiology of FM. Future studies will assess the criteria for feasibility, reliability,
and validity. Revisions of the dimensions will also be required as research advances our understand-
ing of FM.

Received May 10, 2018; Revised September 28, 2018; Accepted October
15, 2018.
Supplementary data accompanying this article are available online at
www.jpain.org and www.sciencedirect.com.
Support was provided by the Analgesic, Anesthetic, and Addictions Clin-
ical Trial Translations, Innovations, Opportunities, and Networks public-
private partnership with the US Food and Drug Administration (FDA),
which has received contracts, grants, and other revenue for its activities
from the FDA, multiple pharmaceutical and device companies, and
other sources. A complete list of current Analgesic, Anesthetic, and
Addictions Clinical Trial Translations, Innovations, Opportunities, and
Networks sponsors is available at http://www.acttion.org/partners. The
views expressed in this article are those of the authors, none of whom
has financial conflicts of interest relevant to the issues discussed in this
article. No official endorsement by the FDA should be inferred.
The authors have no conflicts of interest to declare.
Address reprint requests to Lesley M. Arnold, M.D., Department of Psy-
chiatry and Behavioral Neuroscience, University of Cincinnati College of
Medicine, 260 Stetson Street, Suite 3200, Cincinnati, Ohio 45219. E-mail
address: lesley.arnold@uc.edu
1526-5900/$36.00
© 2018 The Author(s). Published by Elsevier Inc. on behalf of the
American Pain Society This is an open access article under the CC BY-NC-
ND license.
https://doi.org/10.1016/j.jpain.2018.10.008

1
 ARTICLE IN PRESS
2 The Journal of Pain
Perspective: The ACTTION-APS FM taxonomy provides an evidence-based diagnostic system for
FM. The taxonomy includes diagnostic criteria, common features, comorbidities, consequences, and
putative mechanisms. This approach might improve the recognition of FM in clinical practice.
© 2018 The Author(s). Published by Elsevier Inc. on behalf of the American Pain Society This is an open
access article under the CC BY-NC-ND license. (http://creativecommons.org/licenses/by-nc-nd/4.0/)
Key Words: Fibromyalgia, diagnosis, criteria, AAPT, dimensions.
O
ver many decades, there have been efforts to
develop diagnostic criteria for the condition we
now recognize as fibromyalgia (FM). The multiple
symptoms and comorbidities associated with FM make it
difficult to diagnose, and FM is still underdiagnosed and
undertreated.7,34,79 The diagnosis of FM might take
>2 years, with patients seeing an average of 3.7 different
physicians during that time.34 Many health care providers,
particularly in primary care, report unclear diagnostic cri-
teria, a lack of confidence in using existing criteria for
diagnosis, insufficient training or skill in diagnosing FM,
and a lack of knowledge of treatment options.79 There-
fore, despite progress in the understanding and manage-
ment of FM, there remain barriers in the recognition and
diagnosis of FM in clinical practice.
To address problems related to the diagnosis of differ-
ent chronic pain disorders, the Analgesic, Anesthetic, and
Addiction Clinical Trial Translations Innovations Opportu-
nities and Networks (ACTTION) public-private partnership
with the U.S. Food and Drug Administration (FDA) and
the American Pain Society (APS) initiated the ACTTION-
APS Pain Taxonomy (AAPT) to develop a diagnostic system
that would be clinically useful and consistent across
chronic pain disorders. Fillingim et al61 provides more
information about the rationale and background for the
AAPT. In 2013, the AAPT Steering Committee invited L.
M.A., R.M.B., and L.J.C. to be co-chairs of the Fibromyalgia
Working Group. The co-chairs subsequently selected inter-
national FM experts as members of the working group.
The goal of the Fibromyalgia Working Group was to apply
the multidimensional diagnostic framework adopted by
AAPT to FM and evaluate new approaches to the diagno-
sis of FM that might improve the recognition of FM in clin-
ical practice. Briefly, in the AAPT taxonomy, there are 5
dimensions: dimension 1: core diagnostic criteria; dimen-
sion 2: common features; dimension 3: common medical
co-morbidities; dimension 4: neurobiological, psychoso-
cial, and functional consequences; and dimension 5: puta-
tive neurobiological and psychosocial mechanisms, risk
factors, and protective factors.61
As part of the AAPT process, the Fibromyalgia Working
Group members held in-person meetings, teleconfer-
ences, and email communications to review the literature
on FM symptoms and diagnostic criteria and establish
consensus on the approach to FM diagnosis. This article
details the development of the dimensions for FM.
Dimension 1
Core Diagnostic Criteria
There have been many efforts to improve the identi-
fication of patients with FM, and several classifications,
AAPT Diagnostic Criteria for Fibromyalgia
diagnostic and screening criteria have been developed
over the years.11,16,126,162,187-189,193,197 Early efforts
focused on FM as a chronic widespread pain disorder
with other associated symptoms.162,197 The American
College of Rheumatology (ACR) 1990 classification cri-
teria193 eliminated associated symptoms and focused
solely on chronic widespread pain (CWP) (defined as
pain in the left side of the body, pain in the right side
of the body, pain above the waist, pain below the
waist, and axial skeletal pain [cervical spine or anterior
chest or thoracic spine or low back]) and tenderness
(defined as pain on palpation of ≥11 of 18 specific ten-
der point sites on the body). Although the ACR 1990
criteria helped to advance research studies of FM, the
criteria were not intended for use in clinical practice,
did not include commonly associated symptoms, and
required a tender point exam, which was impractical
for use in the clinical setting.74 With the publication of
the 2010 and 2011 criteria,188,189 the definition of FM
moved from a predominantly chronic pain disorder to
a multi-symptom disorder and eliminated the tender
point exam as a requirement for diagnosis. Although
the authors of the 2010/2011 criteria re-emphasized
the importance of associated symptoms, there may
have been too much movement away from chronic
pain as the core symptom of FM.95 Studies of alterna-
tive criteria evaluated a variety of associated symptoms
along with various definitions of widespread pain in
the diagnosis of FM.11,16 The authors of the revised
2016 criteria187 addressed the problem with the 2010/
2011 criteria regarding misclassification of patients
who did not have generalized pain,57 which occurred
because the 2010/2011 criteria do not consider the spa-
tial distribution of painful sites. The 2016 criteria now
require that patients have pain in 4 of 5 regions, called
“generalized pain” to distinguish it from the 1990 defi-
nition of “widespread pain.” Even though there are
different definitions of widespread pain and associated
symptoms, most of the previous FM criteria appear to
identify a similar group of patients most clinicians
would agree have FM.
Based on the review of existing criteria, the consensus
of the Fibromyalgia Working Group was to devise core
diagnostic criteria (dimension 1) that would reflect the
current understanding of FM and be practical for use by
clinicians and to provide a basis for clinical trial inclusion
and exclusion criteria. The multidimensional diagnostic
framework of the AAPT allowed the group to identify
the core symptoms of FM and include other associated
symptoms and signs in dimension 2. The group members
agreed that dimension 1 would include only a core set
of diagnostic symptoms, and that signs such as tender
points would be relegated to dimension 2.
 ARTICLE IN PRESS
Arnold et al
Definition of FM Pain in Dimension 1
The Fibromyalgia Working Group members agreed
that dimension 1 should identify FM as predominantly a
chronic pain disorder. In other words, all patients would
be required to have chronic pain to be diagnosed with
FM. However, the members raised a question about
how to define FM pain, that is, whether FM-related pain
should be defined by the 1990 ACR criteria (CWP) or by
multisite pain (MSP) as in the ACR 2010/2016 criteria.
The main distinguishing feature between CWP and MSP
is that MSP is a simple count of the number of body sites
with pain, whereas CWP requires a specific anatomical
distribution of the pain reported. To address this ques-
tion, members of the working group analyzed data
from large population-based studies of 34,818 subjects
conducted in the United Kingdom.
The first previously published study48 investigated
whether associations between pain and the additional
symptoms associated with FM are different in persons
with CWP as defined by the ACR 1990 criteria compared
to MSP, with or without joint areas. Briefly, 6 studies
were used: the National Child Development (1958 British
birth cohort),13 the Epidemiology of Functional Disorders
(EpiFund),129 the Kid Low Back Pain (Kid LBP),181 the
Managing Unexplained Symptoms (Chronic Widespread
Pain) in Primary Care: Involving Traditional and Accessi-
ble New Approaches (MUSICIAN),122 the Study of Health
and its Management (SHAMA),63 and the Women’s
Health Study (WHEST).15 In all of the population studies,
participants were asked “Have you experienced pain in
the past month lasting at least a day?”; those responding
positively shaded the sites of pain on 4-view body mani-
kins and indicated whether pain had been present for ≥3
months. Manikins were coded for pain at 35 individual
sites. The number of pain sites were determined, includ-
ing whether the subjects met the ACR 1990 criteria for
CWP. MSP was defined as the number of pain sites
needed to reach a prevalence similar to that of CWP (as
defined by the ACR 1990 criteria) from the same popula-
tion. As there are no gold-standard definitions of FM,
and the prevalence differs depending on the criteria
used,95 a prevalence of 2 to 5% was chosen to reflect
both this variability and the expected prevalence using
the ACR 1990 criteria. Information was also collected
across at least 2 studies on each of the following symp-
toms: fatigue (Chalder fatigue32 or SF-36 vitality scale22),
sleep (Sleep Problem Scale91 or 2010 modified prelimi-
nary ACR criteria question), mood (General Health Ques-
tionnaire,72 Hospital Anxiety and Depression Scale,200
PROMIS Global Mental Health score,85 and SF-36 mental
health22), and the presence of somatic symptoms.143
Relationships with pain were determined by multiple
binary logistic regression models, specifically comparing
among those with MSP, and subjects with and without
CWP. Among those reporting the nonpain symptoms
associated with FM (fatigue, sleep disturbance, somatic
symptoms, and mood impairment), there was an
increased likelihood of reporting pain, the magnitude of
which was similar regardless of the pain definition used.
Additionally, there were no indications of differences in
The Journal of Pain 3
the magnitude of the associations by sex. The findings
support the continued collection of both pain and associ-
ated symptoms when classifying FM and highlight that
pain may not require the definition of CWP as used in
the 1990 ACR criteria. Classification of pain simply by
self-reported number of sites distributed throughout the
body, including joint sites, is sufficient when defining the
pain of FM. The number of pain sites needed to define
MSP in FM was found to be ≥8, which is consistent with
previous studies.184
Nonpain FM Symptoms in Dimension 1
The Fibromyalgia Working Group proposed a reduc-
tion in nonpain symptoms for inclusion in dimension 1 as
core diagnostic criteria to reduce the complexity of diag-
nosis and make the FM criteria easier to use in practice.
The Fibromyalgia Working Group identified fatigue and
sleep problems as 2 key associated symptoms for several
reasons. First, these symptoms, along with chronic pain,
occur in most patients with FM.7 Second, pain, sleep dis-
turbance, and fatigue were identified by OMERACT as
core symptoms of FM.133,196 Finally, responder definitions
using fatigue and sleep problems, in combination with
pain and physical function, were shown to be responsive
to change in FM clinical trials.12 Other nonpain symptoms
and signs are included in dimension 2 and may be consid-
ered when evaluating a patient but are not required for
diagnosis. However, more study was required to deter-
mine whether the presence and severity of fatigue and
sleep problems along with MSP would suffice for the
core diagnostic criteria.
A second study was conducted using data from the UK
population-based studies to address this issue and
answer the following questions: 1) What is the preva-
lence of CWP or MSP in conjunction with the key symp-
toms of fatigue and/or sleep problems? Is this similar to
the prevalence we would expect for FM? and 2) If fatigue
and/or sleep problems are present in addition to pain,
how many pain sites would it take to result in the same
prevalence as CWP or FM without the presence of these
symptoms? “Any pain” was defined as a positive
response to the following pain stem question that was
collected across all of the study populations: “Thinking
back over the past month, have you had any aches or
pains that have lasted for 1 day or longer?” The preva-
lence of “any pain” in conjunction with fatigue and/or
sleep problems48 was estimated and subsequently recal-
culated after the addition of each pain site as indicated
by body manikin (eg, 1 site or more, 2 sites or more) until
a similar prevalence of CWP or FM was reached.
There were a total of 28,789 subjects across the stud-
ies (mean age 42−55 years; males 43−52% [WHEST was
conducted only in females]) included in this second
study. The prevalence of CWP (defined per the ACR
1990 criteria) across studies was 12 to 17%, and in each
study the equivalent prevalence was obtained by defin-
ing MSP as ≥8 sites, as noted in Dean et al.48 In separate
analyses using manikins without joint areas included,
MSP was consistently defined as reporting ≥8 sites.
 ARTICLE IN PRESS

4 The Journal of Pain AAPT Diagnostic Criteria for Fibromyalgia

Therefore, joint areas were included in all subsequent
analyses in this study.
The prevalence of CWP in conjunction with fatigue was
6% within WHEST and 7% within SHAMA. Using the
multisite definition of pain (ie, ≥8 of 35 pain sites), the
prevalence of MSP in conjunction with fatigue was 7% in
both populations. The prevalence of CWP and sleep
problems was 6% within WHEST, 6.5% within SHAMA,
and 7% within EpiFund. The prevalence of MSP in con-
junction with sleep problems was 7% across all popula-
tions. Thus, the prevalence of CWP or MSP (≥8 pain sites)
in addition to either fatigue or sleep problems was
between 6 and 7% and was greater than the prevalence
expected for FM (2−5%). To reach a similar population
prevalence expected for FM, ≥10 pain sites are needed in
addition to either fatigue or sleep problems.
The prevalence of CWP in conjunction with fatigue
and sleep problems was 3% within WHEST and 5%
within SHAMA, which is in line with the prevalence
expected for FM. Using an MSP definition of ≥8 of 35
sites, the prevalence of MSP in conjunction with fatigue
and sleep problems was 4% within WHEST and 5%
within SHAMA. Therefore, the prevalence of CWP or
MSP in addition to both fatigue and sleep problems was
between 3 and 5%, similar to the prevalence for FM
established by prior studies.
Additional analyses were conducted to examine the
number of pain sites required to reach expected FM
prevalence using different combinations of pain,
fatigue, and sleep problems. Using the WHEST, SHAMA,
EpiFund, and 1958 databases, at least 13 to 15 pain sites
were needed if the subject had no sleep or fatigue prob-
lems. Using SHAMA, WHEST, and EpiFund, at least 10 to
11 pain sites were needed if the subject had sleep prob-
lems, but no fatigue. In the SHAMA and WHEST data-
bases, at least 10 to 11 pain sites were needed if the
subject had fatigue but no sleep problems. Finally, if
both sleep problems and fatigue were present in the
SHAMA and WHEST databases, at least 6 to 8 sites were
needed to reach the expected FM prevalence.
To reduce the number of possible sites, appropriate sites
were grouped together, while keeping key body areas
separated such as arms and legs. This resulted in a new
body manikin that had only 9 defined sites: head, left
arm, right arm, chest, abdomen, upper back and spine,
lower back and spine (including buttocks), left leg, and
right leg. Another analysis was then conducted using the
4 studies (SHAMA, WHEST [women only], 1958 Birth
Cohort, and EpiFund) to determine a new definition of
MSP based on the 9-point body manikin that produced
the same prevalence as the ACR 1990 CWP definition
from the same population. The results indicated that the
minimum number of sites required to reach a similar
prevalence to that of CWP was between 5 and 6 sites
depending on the study used. A conservative approach
was taken to define MSP as the reporting of ≥6 pain sites
using the 9-point body manikin. Further analysis was
undertaken to assess the association between the new
definition of MSP and the additional nonpain factors
associated with FM, compared with the original MSP def-
inition. This analysis demonstrated that the associations
between the new definition of MSP using a 9-point mani-
kin were generally comparable to those using the origi-
nal MSP definition using a 35-point manikin (data
summarized in Supplementary Tables 1 and 2).
Duration of Symptoms and Presence of
Other Disorders in Dimension 1
When considering the necessary duration of symp-
toms that are required for diagnosis of FM, the working
group consensus was to maintain the 3-month time
frame, which best reflects the chronicity of FM. The
group also agreed that the presence of another pain dis-
order or related symptoms does not rule out a diagnosis
of FM, consistent with the 1990 ACR criteria.193 How-
ever, as noted in Bennett et al16 criteria, a careful clinical
evaluation is recommended to identify any condition
that could fully account for the patient’s symptoms and/
or contribute to the severity of the symptoms.

Number of Pain Sites FM Criteria in Dimension 1

Based on the results of the analyses conducted on the
population-based databases and the consensus of the
Fibromyalgia Working Group, the proposed criteria for
FM dimension 1 require ≥11 pain sites be endorsed on
the 35-point body manikin. However, the working group
considered that the 35-point manikin would likely be
impractical for use by most clinicians and researchers.
Based on the results of the analyses conducted on the
population-based databases and the consensus of the
Fibromyalgia Working Group, the criteria for FM,
dimension 1, are presented in Table 1 and Fig 1. The
pre-shaded areas within the body manikin in Fig 1 were
included to prevent users from counting the same area
twice (for example front and back of the same leg). At

Table 1. AAPT Diagnostic Criteria for Fibromyalgia

Dimension 1: Core Diagnostic Criteria
1. MSP defined as 6 or more pain sites from a total of 9 possible sites (see Fig 1)
2. Moderate to severe sleep problems OR fatigue
3. MSP plus fatigue or sleep problems must have been present for at least 3 months

NOTE. The presence of another pain disorder or related symptoms does not rule out a diagnosis of
FM. However, a clinical assessment is recommended to evaluate for any condition that could fully
account for the patient’s symptoms or contribute to the severity of the symptoms.
 ARTICLE IN PRESS
Arnold et al
Figure 1. Number of painful body sites.
Patients are asked to check the areas in which they experience pain on the 2-view manikins (ignoring the pre-
shaded areas). Alternatively, patients may use the checklist of body sites.
The number of separate sites are summed from a maximum of 9 body sites.
least 6 of 9 pain sites are required along with fatigue or
sleep problems. Fatigue is defined as physical or mental
fatigue judged as at least moderate severity by the
health care professional. Physical fatigue may manifest
as a complaint of physical exhaustion after physical
activity, including an inability to function within normal
limits for activities that constitute normal daily activities
and the requirement for rest periods after activity. Sleep
problems are defined as difficulty falling or staying
asleep, frequent awakening that is disturbing during a
sleep period, or feeling unrefreshed after sleep. These
symptoms must be assessed as at least moderate severity
by the health care professional. In assessing the severity
of fatigue and sleep problems, the clinician may use
multiple sources of information, including patient his-
tory and exam, as well as self-reported questionnaires
or other corroborating data.
Differential Diagnosis
These new criteria for FM recommend that clinicians
evaluate for the presence of other disorders so that
appropriate treatments can be initiated. This can be chal-
lenging in clinical practice because comorbid disorders,
including other chronic pain disorders, are common in
patients with FM.7 Several disorders can mimic FM, such
as hypothyroidism and inflammatory rheumatic diseases.
In addition, some medications may contribute to pain,
The Journal of Pain 5
such as statins, aromatase inhibitors, bisphosphonates,
and opioids (ie, opioid-induced hyperalgesia). However,
these conditions and many others (eg, rheumatoid arthri-
tis, osteoarthritis, systemic lupus erythematosus [SLE], spi-
nal stenosis, neuropathies, Ehlers Danlos syndrome,51
sleep disorders such as sleep apnea, and mood and anxi-
ety disorders121) also co-occur in patients with FM. The
clinician must determine the possible contribution of var-
ious disorders to the patient’s presentation. The presence
of other disorders does not necessarily exclude a diagno-
sis of FM, and all disorders will need clinical attention.
Table 2 summarizes some of the key medical disorders
considered in the differential diagnosis of FM that
require additional assessment, tests, and specific treat-
ment. A description of several differentiating signs and
symptoms are provided in the table, but a detailed
review of the diagnostic tests for each medical disorder is
beyond the scope of this article.
In general, extensive laboratory testing is not necessary
to diagnose FM.7 Screening laboratory tests are some-
times obtained to evaluate other possible causes of
symptoms or signs. These tests include erythrocyte sedi-
mentation rate and/or C-reactive protein, complete
blood count, comprehensive metabolic panel, and thy-
roid function test. Routine testing for rheumatoid factor
or antinuclear antibodies to diagnose FM is not recom-
mended unless the patient has signs or symptoms
suggesting an autoimmune disorder, or if initial
 ARTICLE IN PRESS

6 The Journal of Pain AAPT Diagnostic Criteria for Fibromyalgia

Table 2. Differentiating Key Disorders From Fibromyalgia
MEDICAL DISORDER DIFFERENTIATING SIGNS AND SYMPTOMS

Rheumatologic
Rheumatoid arthritis Predominant joint pain, symmetric joint swelling, joint line tenderness, morning stiffness >1 hour
Systemic lupus erythematosus Multisystem involvement, joint/muscle pain, rash, photosensitivity, fever
Polyarticular osteoarthritis Joint stiffness, crepitus, multiple painful joints
Polymyalgia rheumatica Proximal shoulder and hip girdle pain, weakness, stiffness, more common in the elderly
Polymyositis or other myopathies Symmetric, proximal muscle weakness and pain
Spondyloarthropathy Localization of spinal pain to specific sites in the neck, mid-thoracic, anterior chest wall, or lumbar regions,
objective limitation of spinal mobility due to pain and stiffness
Osteomalacia Diffuse bone pain, fractures, proximal myopathy with muscle weakness
Neurologic
Neuropathy Shooting or burning pain, tingling, numbness, weakness
Multiple sclerosis Visual changes (unilateral partial or complete loss, double vision), ascending numbness in a leg or bandlike
truncal numbness, slurred speech (dysarthria)
Infectious
Lyme disease Rash, arthritis or arthralgia, occurs in areas of endemic disease
Hepatitis Right upper quadrant pain, nausea, decreased appetite
Endocrine
Hyperparathyroidism Increased thirst and urination, kidney stones, nausea/vomiting, decreased appetite, thinning bones,
constipation
Cushing syndrome Hypertension, diabetes, hirsutism, moon facies, weight gain
Addison disease Postural hypotension, nausea, vomiting, skin pigmentation, weight loss
Hypothyroidism Cold intolerance, mental slowing, constipation, weight gain, hair loss

inflammatory indices are abnormal (recognizing that
some patients with rheumatoid arthritis or SLE may have
normal erythrocyte sedimentation rate and/or C-reactive
protein values). Depending on symptoms, medical history
and physical exam, other tests such as ferritin, iron-bind-
ing capacity and percentage of saturation, and vitamin
B12 and vitamin D levels may be indicated.
Dimension 2
Common Features
Features that are not included in dimension 1 but may
be used to support a diagnosis of FM are described below.
Tenderness, defined as a generalized sensitivity of soft
tissues and muscles to pressure that would not normally
be expected to cause pain, is a universal complaint and in
the 1990 ACR criteria was codified by the “tender point”
examination.193 Although the tender point evaluation
has been eliminated from the more recent criteria, with
the exception of the 2012 FM screen,11,126 the symptom
of “tenderness to touch” is included in the 2014 Bennett
et al criteria16 and the 2012 FM screen11,126; this question
was ranked third in importance as a diagnostic question
in the 2014 Bennett et al criteria.16 A tender point exam,
either as part of the 1990 ACR criteria193 or an abbrevi-
ated version,11,126 may provide valuable information to
the clinician about the overall status of the patient’s con-
dition74 and support the diagnosis of FM.
Dyscognition (eg, trouble concentrating, forgetful-
ness, and disorganized or slow thinking) is increasingly
recognized as a major feature of FM, with dysfunction
being seen in working memory and executive func-
tion.70 Self-reported questionnaires are useful to screen
for dyscognition in patients with FM, but full
neuropsychological testing may be required to delin-
eate the extent of cognitive dysfunction.163 In brain
functional magnetic resonance imaging (fMRI) stud-
ies,71,170 FM patients showed lower activation in the
inhibition and attention networks and increased activa-
tion in other areas. Because inhibition and pain percep-
tion may use overlapping networks, resources taken up
by pain processing may be unavailable for other
processes.71
Musculoskeletal stiffness is experienced, in varying
degrees, by all FM patients.17 Interestingly, stiffness in
FM patients is difficult to distinguish from the stiffness in
conditions such as rheumatoid arthritis, polymyalgia
rheumatica, and ankylosing spondylitis. FM-related stiff-
ness, like that described in these other conditions, is typi-
cally more severe in the early morning and improves as
the day goes on.86 However, unlike these other condi-
tions, it is not responsive to corticosteroids.37 This feature
is only used in the 2014 Bennett et al criteria and was
ranked fifth in importance as a diagnostic question.16
Environmental sensitivity or hypervigilance, manifesting
as intolerance to bright lights, loud noises, perfumes and
cold, is a common complaint of FM patients. It is probably
a reflection of central sensitization.54,142 A recent study has
provided clues as to how sensitivity to bright lights modu-
lates brain connectivity, such that previously innocuous
inputs are experienced as being painful.125 This feature is
only used in the 2014 Bennett et al criteria16 and was
ranked second in importance as a diagnostic question.
Epidemiology
The prevalence of FM varies from .5 to 12%, depend-
ing on the population sampled and the method of ascer-
tainment.104,128,138,144,158,177,182,192 Females outnumber
 ARTICLE IN PRESS
Arnold et al
males in a ratio of about 3:1 in studies that do not use
tender points as a criterion. Major ethnic variations in
prevalence have not been well documented.151 A survey
in 5 European countries (Germany, Italy, Portugal,
France, and Spain), using the 1990 ACR criteria,193 esti-
mated prevalence of FM in the general population and
also in 8 participating rheumatology clinics; the overall
presence of FM in the 5 countries ranged from 2.9 to
14% in outpatients treated in rheumatology practices.21
The prevalence of FM increases with age, rising in mid-
dle age (50−59 years) and then dropping off in the oldest
age groups (80+ years).191 The average age of onset is
between 30 and 50 years. FM in children is now well recog-
nized. Estimates of the general population prevalence of
FM in children and adolescents vary from 1.0% up to
6.2%.24,27,36,135,199 FM in adolescents is associated with
significant impairment in physical function and lower per-
ceived health status compared with peers.98,101 There is
often peer-related discrimination with resulting unpopu-
larity, isolation, and school absenteeism.99,100 As peer
relationships are a key element in the psychological devel-
opment of children, the occurrence of FM can lead to
adjustment problems and other psychopathology in adult-
hood.116 The symptoms of FM persist into adulthood for
the majority of patients experiencing childhood or adoles-
cent FM.98
The incidence of FM was determined in a population-
based sample of Norwegian women between the ages
of 20 and 49 years who were followed for 5.5 years.65
The incidence of FM among women who began the
observation period without any complaints of musculo-
skeletal pain was 3.2%, corresponding to an average
annual incidence of 583 cases/100,000 women between
20 and 49 years of age. For those with any self-reported
pain at the beginning of the study, the incidence was
25%, and risk factors for the development of FM
included pain for ≥6 years, self-assessed depression, lack
of professional education, and the presence of 4 or
more associated symptoms, such as disturbed bowel
function, unrefreshing sleep, paresthesia, and subjective
swelling. In another cohort of 1,198 early arthritis
patients followed by rheumatologists, the incidence of
FM was 6.77/100 person-years in the first year after diag-
nosis of arthritis, and declined to 3.58/100 person-years
in the second year. Pain severity and poor mental health
predicted FM risk.114
Dimension 3
Common Medical and Psychiatric
Comorbidities
FM is associated with many comorbidities that may be
categorized as other somatic pain disorders, psychiatric
conditions, sleep disorders, rheumatic diseases, and
other conditions. It is commonly conjectured that many
of these associations are a result of central sensitiza-
tion,198 but this mechanism cannot explain all associa-
tions. Chronic fatigue syndrome is a condition that has
considerable overlap with FM, with the predominance
of pain an identifier of FM.134 Among the somatic pain
The Journal of Pain 7
conditions that associate with FM, the best recognized
are irritable bowel syndrome, chronic pelvic pain and
interstitial cystitis, chronic head and orofacial condi-
tions such as temporomandibular disorder, otologic
symptoms, chronic headaches, and migraine disor-
der.2,6,90,119,124,152 Psychiatric conditions that associate
with FM include major mood disorder (eg, major depres-
sive disorder and bipolar disorder), anxiety disorders
(eg, generalized anxiety disorder, panic disorder, post-
traumatic stress disorder, social phobia, and obsessive
compulsive disorder), and substance abuse disorder.10,20
Sleep disorders that can occur concomitantly with
FM include obstructive and central sleep apnea and rest-
less leg syndrome.153,166 Various rheumatic conditions,
both inflammatory and degenerative, may act as a
peripheral pain generator and associate with FM
including inflammatory rheumatic diseases such as
rheumatoid arthritis, systemic lupus erythematosus,
scleroderma, Sjogren’s syndrome and others, and osteo-
arthritis.14,23,33,59,80,89,137 Joint hypermobility as in joint
hypermobility syndrome and Ehler’s Danlos syndrome
may predispose to recurrent pain and subsequent FM.31
The association with rhinitis and urticaria is especially
interesting, as gene expression profiling in FM has
reported an up-regulation of genes involved in allergic
responses.96 Obesity is common in patients with FM and
is associated with greater pain severity, poorer sleep,
and reduced physical strength and flexibility.73,141
Dimension 4
Neurobiological, Psychosocial, and
Functional Consequences
General Outcome, Including Cost of FM
Long-term outcome data for FM are limited.
Although available studies indicate that symptoms of
FM often persist, many patients are able to identify
strategies over time that can moderate symptoms. In
one of the earliest prospective studies, 538 FM patients
from U.S. rheumatology centers that had a special
interest in FM were followed every 6 months for
7 years.185,186 Most outcome measures, including func-
tional disability, did not change or worsened slightly
over time. Sixty percent of patients who were diagnosed
with FM rated their health as fair or poor. FM patients
averaged 1 outpatient visit each month. Costs increased
over the 7 years, with a mean yearly per-patient cost of
$2,274 in 1996 U.S. dollars.
In single-center prospective reports, there was also lit-
tle change in symptoms or function over time. In 1
report from Boston, all patients had persistent FM symp-
toms and 55% reported moderate or severe pain after
10 to 15 years.60,103 However, 70% of patients reported
that their overall FM symptoms were a little or a lot bet-
ter than when first diagnosed, and 50% reported that
they were doing well. Sleep disturbances were the most
persistent symptom. In a report from the U.K., 97% of
FM patients still had symptoms, and 60% felt worse
than their initial visit.112
 ARTICLE IN PRESS
8 The Journal of Pain
Another multicenter study conducted in the U.S. of
1,555 FM patients found that pain, fatigue, and global
well-being had not changed much over 11 years, but
there was significant individual variability in outcome
measures.179 In contrast, in a prospective study of FM
patients followed in Australian primary care, 47% no
longer fulfilled FM criteria and 24% were in remission,76
and one-third of FM patients in Canada experienced
good outcomes at 3 years.149 An ongoing prospective
study from Spain comparing women with FM to
matched controls found a greater impact on physical
than on psychological outcomes, although both were
markedly impaired.157 That group also noted the com-
bined effect of lack of physical fitness, obesity, and
mood disturbances on poor quality of life in FM.164
FM has been associated with significant direct medical
costs.110 In a large U.S. health care database of >30,000
FM patients, health care costs were 3 times greater than
controls.18 In another survey of 16,000 patients with FM,
there were greater comorbidities, physician visits, and
costs compared with controls.111 In Quebec, the mean
direct annual cost of FM was estimated to be $3,804,
and an average of 6 days were lost due to pain during
the prior 3 months.110 Indirect costs are also high,110
mainly driven by lost work productivity, with the high-
est direct annual cost in the U.S. compared to France
and Germany. 107 In a recent report from Australia, one-
quarter of working FM subjects stopped work within
5 years of the diagnosis and one-third were receiving
financial support because of FM.78
Compared with controls, patients with CWP had worse
quality of life, greater disability, mood and sleep distur-
bances, cardiovascular comorbidity, and higher mortality
rates.136 In the 2012 U.S. National Health Interview Sur-
vey, FM patients had high levels of self-reported pain,
physical and psychological comorbidities, and high medi-
cal costs, as well as high rates of Social Security and work
disability.180 Fifty-six percent of FM patients <65 years
old were unable to work compared with 6% without FM.
Disability payments in the prior year were 30% in FM
patients compared with 3% in controls.
In a more recent study from Canada, one-third of FM
patients were receiving disability payments.62 Disability
compensation was associated with illness severity, num-
ber of medications used, and previous employment in
physically demanding jobs. Illness burden was evaluated
in 125 individuals not complaining of CWP, 176 with
CWP, and 171 with FM.156 The FM patients had more
comorbidities, pain-related medications, poorer health
status and function, worse sleep, lower productivity,
and greater health care costs. Those investigators also
reported that over 2 years, about one-quarter of FM
patients no longer met criteria for FM and that symp-
toms wax and wane.3
Morbidity and Mortality
In older European men, CWP was associated with
slower cognition113 and increased frailty.178 There was a
1.25-fold higher risk of stroke in FM compared with con-
trols and a 2.3-fold higher risk in younger subjects.175
AAPT Diagnostic Criteria for Fibromyalgia
Initial reports suggested that FM and CWP were associ-
ated with increased mortality, including from cancer
and cardiovascular disease.130,171 Although there has
been variability across studies conducted,56,190 the larg-
est study that has examined this (UK Biobank)120 com-
bined into a meta-analysis has confirmed that patients
with CWP do have an important excess risk of death. As
expected, suicidal ideation and risk of suicide were asso-
ciated primarily with depression and global mental
health and were much greater in patients with FM than
in patients with low back pain and controls.30,94
Dimension 5
Putative Neurobiological and
Psychosocial Mechanisms, Risk Factors,
and Protective Factors
Risk Factors and Comorbidities
Individuals who develop FM nearly always have a life-
long history of chronic pain in various regions of the
body, as well as other central nervous system symptoms
such as fatigue, sleep, memory, and mood difficulties.7
Often beginning in childhood or adolescence, individuals
who eventually go on to develop FM are more likely to
experience headaches, dysmenorrhea, temporomandibu-
lar joint disorder, chronic fatigue, irritable bowel syn-
drome and other functional GI disorders, interstitial
cystitis/painful bladder syndrome, endometriosis, and
other regional pain syndromes (especially back and neck
pain).1,40,88 As a result, many in the field have started to
believe that these “centralized” pain states are best
thought of as a single, lifelong disease that merely tends
to manifest in multiple different bodily regions over
time.173,183,195
In addition to FM patients frequently having a per-
sonal lifetime history of chronic pain, a strong family his-
tory of chronic pain is often identifiable. The first-degree
relatives of FM patients are 8 times as likely to have this
condition as the family members of controls, and also
have very high rates of other chronic pain states.9 This
familial and personal co-aggregation of conditions that
includes FM was originally collectively termed affective
spectrum disorder87 and, more recently, central sensitiv-
ity syndromes,198 chronic multisymptom illnesses, and
chronic overlapping pain conditions. In population-based
studies, the key symptoms that often co-aggregate
besides pain are fatigue, memory difficulties, and mood
disturbances.66,67 Twin studies suggest that »50% of the
risk of developing FM or related pain conditions such as
irritable bowel syndrome and headache is genetic and
50% environmental.102
The environmental factors that are most likely to trig-
ger the development of FM are various types of
“stressors.” These stressors include the following: early
lifetime adverse events, medical illness (including infec-
tions), trauma, and psychosocial stressors.131 For example,
FM or similar illnesses are found at much higher than
expected rates in individuals who have experienced cer-
tain types of infections25,29 (eg, Epstein Barr virus, Lyme
 ARTICLE IN PRESS
Arnold et al
26,132
disease, Q fever, viral hepatitis), trauma (eg, motor
vehicle collisions), and deployment to war.115 FM also is
very commonly seen as a comorbidity in other chronic
pain conditions such as osteoarthritis, rheumatoid arthri-
tis, and lupus.14,59,137 This phenomenon had previously
been termed “secondary FM”; however, because this is
so common and might occur in a subset of nearly any
chronic pain cohort, the preferred terminology is that
there has been a centralization of pain that manifests as
co-morbid FM. FM, especially the “primary” form, is also
very comorbid with early life and current stress, and
many, if not most, individuals will have a lifetime history
of a psychiatric disorder such as depression or anxiety.58
There is typically more psychiatric and psychological
comorbidity seen in tertiary care settings or in individuals
who are refractory to treatment.
Pathophysiology
Although few would purport that there is an animal
model that mimics all of the key clinical features of FM,
nonetheless animal models can be very helpful in under-
standing the pathogenesis of this condition.160 Animals
develop the critical features of central sensitization or
centralization of pain when exposed to swim stress,168
neonatal separation from their mothers,147 and many
other nonpainful stimuli.160 Features of central sensiti-
zation and animal pain behaviors consistent with dif-
fuse pain are also seen when central nervous system
neurotransmitters are purposefully altered in the direc-
tion found in FM. For example, chronic reserpine admin-
istration, which depletes bioamines, leads to features
consistent with FM,159,169 as does directly increasing glu-
tamate levels in the insulae.
The strong familial predisposition to FM has led many
to study specific genes that may be associated with a
higher risk of developing FM. First, candidate gene stud-
ies showed that genetic findings such as the serotonin
5-HT2A receptor polymorphism T/T phenotype, seroto-
nin transporter, dopamine 4 receptor, and COMT (cate-
cholamine o-methyl transferase) polymorphisms all
were noted in higher frequency in FM patients than
controls. Subsequent studies confirmed some of these
associations, whereas others did not.28,53 Subsequent
larger genome-wide linkage and candidate gene studies
identified other putative targets.8,161 Linkage studies
confirmed the strong genetic contribution to FM and
suggested linkage of FM to the chromosome 17p11.2-
q11.2 region.8 The large candidate gene study identified
significant differences in allele frequencies between
cases and controls for 3 genes: GABRB3 (rs4906902,
P = 3.65 £ 10−6), TAAR1 (rs8192619, P = 1.11 £ 10−5), and
GBP1 (rs7911, P = 1.06 £ 10−4). These 3 genes, and 7
other genes with suggestive evidence for association,
were examined in a second, independent cohort of FM
patients, and evidence of association in the replication
cohort was observed for TAAR1, RGS4, CNR1, and
GRIA4.161 Because classic genetic studies have not yet
identified strong, reproducible polymorphisms or haplo-
types associated with FM, and because there is clear evi-
dence of environmental factors such as stress playing a
The Journal of Pain 9
prominent role in the pathogenesis, other groups have
postulated that epigenetic findings might be important
in FM.35 There is also emerging evidence of functional
genetic polymorphisms affecting pain severity in FM.109
The physiological hallmark of FM, centralization of
pain or central sensitization, is thought to be aug-
mented central pain processing. This was originally
identified in FM (and still can be clinically) by noting
that an individual is diffusely tender to palpation. In
1990, when the original classification criteria for FM
were first published, this feature of diffuse tenderness
was incorporated into the diagnostic criteria by requir-
ing that an individual had a certain number of tender
points (≥11), in addition to CWP to qualify for this diag-
nosis.193 Subsequent studies using more sophisticated
measures of experimental pain testing showed that indi-
viduals with FM are more tender everywhere in the
body, not just in the 18 regions considered to be
“tender points.”145,146 Subsequent experimental pain
testing studies have identified multiple potential mech-
anisms that may be responsible for pain amplification in
FM, including a decrease in the activity of descending
analgesic pathways,97,108 an increase in pain facilitatory
pathways,165 and a diffuse increase in the processing of
all sensory stimuli (not just pain).68,69 The notion that
FM and related syndromes might represent biological
amplification of all sensory stimuli has significant sup-
port from functional imaging studies that suggest that
the insula is the most consistently hyperactive region, as
this region is critical in sensory appraisal, with the poste-
rior insula serving a purer sensory role, and the anterior
insula being associated with the emotional processing
of sensations.44,45,49,172,174
These initial observations that individuals with FM
were diffusely tender led to subsequent functional,
chemical, and structural brain neuroimaging studies that
have been among the best “objective” evidence that the
pain in FM is real.82 These methods, such as fMRI, clearly
demonstrate that when individuals with FM are given a
mild pressure or heat stimuli, that most individuals would
feel as “touch” rather than “pain,” they experience pain
and similar brain activation patterns in brain areas
involved in pain processing.43,75 fMRI has also proved
useful in determining how comorbid psychological fac-
tors influence pain processing in FM. For example, in FM
patients with variable degrees of comorbid depression,
the anterior insula and amygdala activations were corre-
lated with depressive symptoms, consistent with these
“medial” and pre-frontal brain regions being involved
with affective or motivational aspects of pain processing
(and being more closely related to unpleasantness rather
than the sensory intensity of pain).19 A more recent
advance in the use of fMRI is to look at the extent brain
regions are functionally “connected” to each other, that
is, simultaneously activated (or deactivated).148 The
advantage of resting-state connectivity analysis is that it
is a window into brain changes associated with the
chronic, ongoing spontaneous pain common in FM. Indi-
viduals with FM have increased connectivity between
brain regions involved in increasing pain transmission
and neural networks not normally involved in pain, such
 ARTICLE IN PRESS
10 The Journal of Pain
as the default mode network, and the degree of this
hyper-connectedness is related to the severity of ongoing
pain.139,140 During a painful stimulus, connectivity is
decreased between key antinociceptive regions (eg, the
brainstem—the origin of descending analgesic pathways)
and a region previously identified to be a potential
source of dysfunctional pain inhibition in FM.92,93 Imag-
ing studies have confirmed quantitative sensory testing
studies that these individuals are more sensitive to a
number of sensory stimuli other than pain, and that
machine-learning paradigms can accurately distinguish
FM from non-FM patients with >90% accuracy using
these results.117,118
Other imaging techniques have been used to identify
the neurotransmitter abnormalities that may be driving
the pain amplification seen in FM and other chronic pain
disorders. Positron emission tomography studies show
that attenuated dopaminergic activity may be playing a
role in pain transmission in FM, and there is evidence of
decreased m opioid receptor availability (possibly owing
to increased release of endogenous m opioids) in FM.83,194
This latter finding as well as previous studies showing
increases in endogenous opioids in the cerebrospinal fluid
of FM patients has been suggested as evidence of why
opioid analgesics clinically appear to not be effective in
FM. There are increases in brain concentrations of the
body’s major excitatory neurotransmitter, glutamate, in
pain-processing regions such as the insula in FM.81 This
finding has also been noted in the cerebrospinal fluid in
FM.155 Drugs such as pregabalin and gabapentin likely
work in FM in part by reducing glutamatergic activity.123
Individuals with FM that had the highest pretreatment
levels of glutamate in the posterior insula were those
most likely to respond to pregabalin.84 When pregabalin
led to improvement in symptoms in these individuals,
there was normalization of fMRI and connectivity find-
ings, all suggesting that this neurotransmitter is playing a
critical role in the pathogenesis of FM in some individuals.
Conversely, magnetic resonance spectroscopy has recently
been used to demonstrate low levels of GABA in several
brain regions.64 This likely accounts for the efficacy of
drugs such as gamma-hydroxybutyrate in FM.154 This find-
ing may also suggest biological plausibility for the finding
that FM patients who have low alcohol consumption
(compared to none or high) have fewer symptoms and
better functionality.105
Because of the link between FM and exposure to
stress, and because both the neuroendocrine and
autonomic nervous systems could cause many of the
symptoms of FM, these factors have been fairly
extensively studied.39,46,50 In fact, for several decades
after it was understood that conditions such as FM or
chronic fatigue syndrome were not due to inflamma-
tion or infection, these areas were receiving consider-
able attention. The problem is that this research
has generally yielded inconsistent findings and treat-
ment studies targeting these systems have failed;
therefore, these factors are now generally thought
to play a role in some individuals, but not to be cen-
tral pathogenic factors in all individuals with these
conditions.4,42,47,50,127,150
AAPT Diagnostic Criteria for Fibromyalgia
Although most agree that the core symptoms of FM
are likely because of changes in the central nervous sys-
tem, peripheral factors also play an important role in
both the pathogenesis and treatment of FM. For exam-
ple, some elements of the processes of central sensitiza-
tion can be worsened or driven by ongoing nociceptive
input. Thus, it is likely that the many individuals with
FM that also have comorbid conditions causing ongoing
peripheral nociceptive input (eg, myofascial pain, osteo-
arthritis, obesity52) would potentially benefit from ther-
apies aimed at reducing the peripheral drive of central
sensitization, as has been shown in a short-term study.5
In fact, one of the major areas of study needed for these
conditions is to try to differentiate which individuals
have these phenomena that are being driven from the
central nervous system and which may be driven by
ongoing peripheral nociceptive input.
Although the prevailing view is that FM is not an
autoimmune disorder and that classic anti-inflammatory
agents are not of benefit in this condition, there are
some data suggesting that the immune system may be
playing a role in its pathogenesis.77 Some have specu-
lated that diet or obesity could contribute to this low-
grade inflammation in FM and might be a potential tar-
get for therapy, and others have posited that this may
provide evidence of microglia involvement in FM. There
is also a current ongoing controversy regarding the
meaning of finding decreased intra-epidermal nerve
fiber density (ie, small-fiber neuropathy) in FM. There is
no question that this has been shown in several stud-
ies38,55,106; however, it might be that this is a nonspecific
finding that has now been noted in >50 different pain
and nonpain conditions.38
Discussion
A new diagnostic framework was established by the
AAPT to improve the diagnosis of chronic pain disorders.
The AAPT Fibromyalgia Working Group addressed the
current state of FM criteria for diagnosis and determined
that an alternative to existing criteria might improve the
identification of FM patients. The ACR 1990 classification
criteria for FM was considered to be impractical for use
owing to problems related to the tender point exam,
which was difficult to perform and standardize in clinical
settings. The tender point exam was also biased toward
women, who are more sensitive to a tender point exam
than men, and was not an accurate measure of hyperal-
gesia due to influence by subjective distress.74 The ACR
2010/2011/2016 criteria eliminated the tender point
exam and instead defined FM as a multi-symptom disor-
der. The appearance of the 2010 criteria created some
controversy and confusion, and since 2010, alternative
approaches to the diagnosis of FM have been proposed.
The challenge shared by all attempts to define criteria
for FM is that there is no gold standard for FM diagnosis.
Until the pathophysiology is better understood and bio-
markers are identified, the diagnosis relies on patient
report and clinical assessment. Although the criteria pub-
lished to date seem to identify a similar group of
patients, the goal of the Fibromyalgia Working Group
 ARTICLE IN PRESS
Arnold et al
members was to make the diagnosis of FM practical for
clinicians and useful for researchers, and to capture the
key symptoms of the disorder. The AAPT taxonomy offers
a new approach by defining core criteria and including
other associated symptoms and signs, comorbidities, and
impact on function in other dimensions. This taxonomy
allows the clinician and researcher to focus on a more
limited number of core symptoms for diagnosis, while
allowing the many other associated symptoms and signs
to be included in dimension 2, which will support the
diagnosis of FM.
Based on consensus meetings and analyses of several
population-based studies to assess definitions of wide-
spread pain and determine the best combination of
pain and symptoms to identify FM patients, the Fibro-
myalgia Working Group developed new criteria for FM
in dimension 1. The group determined that widespread
pain was the core symptom of FM and, as in the ACR
1990 criteria, all patients should meet this criterion.
Based on the results of the data analysis of multiple
population based studies and other studies,41 the group
selected MSP with a minimum number of required sites
regardless of their anatomical distribution (instead of
the ACR 1990 widespread pain criteria) (Fig 1).
Although pain is the main symptom of FM, other
symptoms are reported to be clinically significant by
patients and are sometimes more disabling than pain.
The new AAPT diagnostic criteria include 2 other symp-
toms, fatigue and sleep problems, which are most com-
monly reported by FM patients. Based on the results of
the analysis of multiple population-based studies, the
presence of MSP in combination with moderate to
severe fatigue or sleep problems was sufficient to iden-
tify the FM patients. This simplified the criteria so that
no scoring of associated symptoms was required. Sleep
problems identified by FM patient include difficulty fall-
ing and staying asleep and unrefreshing sleep—any or
all of these problems can be considered when assessing
sleep problems. Similarly, fatigue may include mental
and/or physical fatigue. Although the analyses of data
from the population-based studies offered several
approaches to FM diagnosis, the working group consen-
sus was to focus on at least 6 of 9 sites of pain in combi-
nation with either fatigue or sleep problems to allow
some flexibility (although most patients will have both
sleep problems and fatigue, there are some patients
who report only 1 of the symptoms). Relegating other
symptom domains and signs to dimension 2 allows them
to be considered when evaluating a patient but not be
required for diagnosis.
The main goal of the AAPT Fibromyalgia Working
Group was to develop the AAPT dimensions for FM. In
the process, the group devised new core criteria for the
diagnosis of FM with the support of analyses of data
from a large-scale population-based post hoc study.48
There are several limitations to using this approach to
identify core symptoms of FM. as detailed in Dean et
al48 In developing the new diagnostic criteria, we
attempted to approximate the generally accepted prev-
alence of FM in the analyses. This would seem to present
a logical conundrum for a new diagnostic system.
The Journal of Pain 11
Nevertheless, the prevalence proportions typically
reported using the ACR 1990 criteria for FM are consid-
ered to have face validity, which seemed a reasonable
reference point to adopt. MSP was defined here to iden-
tify a population with similar prevalence to CWP, and
the resulting overlap may limit the ability to detect dif-
ferences between the 2 groups. The overlap demon-
strated was 60 to 76%, with a substantial number of
individuals exclusive to 1 group and with differences in
pain chronicity between definitions. This indicates that
the similarities demonstrated between the MSP and
CWP definitions and their relationship to other symp-
toms associated with FM cannot be attributed solely to
the overlap of individuals.
To assess the relationship between pain and the other
associated symptoms of FM, bivariate analyses were con-
ducted across multiple study populations. A fully
adjusted model, containing all predictors, could not be
performed, as no single study contained all measures.
Although this did not prevent the study from assessing
these relationships individually, future studies evaluat-
ing these in the context of the other symptoms would
be beneficial.
CWP was assessed using 4-view body manikins, pres-
ent across all study populations, primarily because the
2011 modification of the 2010 FM criteria was not pres-
ent in any of the studies used. The use of a body manikin
has become 1 standard way to collect information from
subjects on their sites of pain, and has been shown to
have construct validity and to be reliable.176 There has
been variability in how authors have defined CWP; but,
the greatest consistency has come in the use of the defi-
nition of CWP within the ACR 1990 criteria for fibromy-
algia. However, because these criteria did not specify
how they should be operationalized, there is still possi-
ble variation.120,167 Despite the difference in the meth-
ods of ascertaining pain, the resulting number of pain
sites needed to define MSP is consistent with other
studies.184
Despite these limitations, the analyses demonstrated
that the features of FM could be defined in multiple
ways. The consensus of the AAPT working group was to
simplify the diagnostic criteria to facilitate the identifica-
tion of FM in clinical practice and for the purpose of
research. We concluded that chronic pain remains the
core symptom of FM, and 2 key associated symptoms
(fatigue and sleep disturbance) are important in under-
standing and treating FM. The AAPT working group con-
sidered the question of whether to require both fatigue
and sleep disturbance in dimension 1. However, based
on the clinical experience of the working group mem-
bers, individuals with FM may at a single point in time
have either fatigue or sleep disturbance; although, if
they are followed longitudinally, they typically develop
both problems over time.
We gathered a group of international clinical and
research experts in the field of FM to have broad input
in the process. However, the resulting development of
the 5 dimensions will need to be assessed by other
groups, and the core diagnostic criteria will require fur-
ther study and validation. We believe that the criteria
 ARTICLE IN PRESS
12 The Journal of Pain
will be useful across all clinical settings, including pri-
mary, secondary, and tertiary practices, but will also
require additional study. A global alignment of taxon-
omy for pain disorders is an important long-term goal.
The AAPT is multidimensional, which makes it unique
compared with other existing and in-development diag-
nostic criteria. We hope that this multidimensional
approach will increase the value of the AAPT for both
clinical research and clinical practice. Additional studies
are needed to assess the prevalence of FM using the
new definition. We have cited many of the key studies
relevant to the development of the dimensions; how-
ever, owing to the rapidly evolving field, the vast
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